Team Player Medical Screening Form

Hampstead and Westminster HC Player Medical Screening and Injury declaration 2020/21
Contact Details
Name
First NameLast Name
Squad
Birth Date
DayMonthYear
Age
Mobile Phone
Area CodePhone Number
Home Phone
Area CodePhone Number
E-mail

Confirmation Email
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
In Case of Emergency/Next of Kin
Name
First NameLast Name
Contact number
Area CodePhone Number
Alternative contact number
Area CodePhone Number
Health & Medical Information
Do you suffer from any general health problems? eg: Asthma, Diabetes, Seizures
If Yes, please give full details
Have you been diagnosed with a serious illness/condition in the past? eg: Cancer, Heart conditions
If Yes, please give full details
Are you taking any medication at present?
Other
If Yes, please give full details
Do you have any allergies? eg: medication, latex, plasters, strapping, food
If Yes, please give full details
Are you currently injured?
If Yes, please give full details
Have you had any serious injuries this season that caused you to miss training/playing for more than 2 weeks?
If Yes, please give full details
Have you had any major injuries in your career that required you to miss training/playing for more than 4 weeks?
If Yes, please give full details
Have you suffered from a head injury/concussion in the past 4 weeks?
If Yes, please give full details
Please upload any relevant medical reports
Upload a File
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Consent to Assessment and Treatment
At times the medical staff will have to liaise with the referee, coaching staff, management staff and attending medical practitioners regarding injuries. However, any of the personal medical details on this form will only be given with your permission. The details will be kept confidential within the medical team.
At sporting events, it is not always possible to provide privacy when being assessed and/or treated. Should you and your practitioner decide privacy is needed or wanted then a suitable private area will be provided if possible.
This form is your decleration of consent to assessment and treatment.
Full Name
First NameLast Name
DayMonthYear
I (named above) consent to be examined on the field of play and/or in a designated area for assessment should an injury occur. I consent to receive manual therapy 'on pitch' and in a designated area. I consent to receive care following an initial 'on pitch' assessment.
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